Primary Care — Sports Physical Template
The Sports Physical Template is designed for primary care providers, pediatricians, and family medicine physicians conducting pre-participation physical examinations (PPE) for athletes. This template documents the comprehensive evaluation required for sports clearance including medical history, cardiovascular screening, musculoskeletal assessment, and clearance determination. The template supports appropriate billing for sports physicals (CPT 97169-97171) and includes sections for sport and level of participation, medical history including cardiac risk factors and previous injuries, family history of sudden cardiac death or other relevant conditions, physical examination including cardiovascular, pulmonary, musculoskeletal, and neurological systems, clearance determination with any restrictions or recommendations, and follow-up requirements. This template ensures thorough pre-participation evaluation, identifies athletes at risk, supports appropriate clearance decisions, and protects both athletes and providers through comprehensive documentation. Ideal for primary care practices, pediatric practices, sports medicine clinics, and school-based health centers conducting sports physicals.
Template
Visit Information
Sport: [Sport name]
Level: [Recreational / School / Competitive / College / Professional]
Season: [Sport season]
Date of last sports physical: [Date]
Medical History
Previous injuries: [List injuries and dates]
Previous surgeries: [List if relevant]
Current medications: [List]
Allergies: [List]
Chronic conditions: [List]
Cardiac symptoms: Chest pain, palpitations, syncope, shortness of breath with exertion
Family history: Sudden cardiac death, heart disease, Marfan syndrome, other relevant conditions
Physical Examination
Vital signs: BP, HR, RR, Temp, Height, Weight, BMI
General: Appearance, body habitus
Cardiovascular: Heart rate, rhythm, murmurs, pulses
Pulmonary: Clear to auscultation, no wheezes
Musculoskeletal: [Screen for joint instability, range of motion, strength]
Neurological: [If indicated]
Vision: [Visual acuity if required]
Hernia: [If indicated for males]
Assessment
1) Pre-participation physical examination
- Cardiovascular risk: Low / Moderate / High
- Musculoskeletal concerns: None / [Specify]
- Other concerns: [Specify]
Clearance Determination
☐ Cleared for all sports without restrictions
☐ Cleared with recommendations: [Specify]
☐ Cleared with restrictions: [Specify restrictions]
☐ Not cleared: [Reason and recommendations]
Plan
1) Clearance: [As determined above]
2) Recommendations: [Activity modifications, follow-up, further evaluation if needed]
3) Follow-up: [If needed]
Patient/Parent Education
Risks discussed, injury prevention, warning signs, when to seek care.
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